The Community Reinforcement Approach

1 The Community Reinforcement ApproachA Guideline developed for the behavioral Health recovery Management projectRobert J. Meyers and Daniel D. SquiresUniversity of New Mexico Center on Alcoholism, Substance Abuse and AddictionsAlbuquerque, New MexicoThe behavioral Health recovery Management project is an initiative ofFayette Companies, Peoria, IL; Chestnut Health Systems, Bloomington, IL;and the University of Chicago Center for Psychiatric project is funded by the Illinois Department of Human Services'Office of Alcoholism and Substance J. Meyers, is a Research Associate Professor in Psychology at the University ofNew Mexico based at the Center on Alcoholism, Substance Abuse and Addictions (CASAA), andhas been involved in research on treatment of alcohol problems for more than twenty-five trained in Nathan Azrin's lab, he was a therapist and collaborator in the first outpatienttrial of the Community Reinforcement Approach (CRA; Azrin, Sisson, Meyers, & Godley, 1982), andother early outpatient studies of CRA (Mallams, Hall, Godley, & Meyers, 1982).

2 He is senior authorof the only therapist manual on CRA (Meyers & Smith, 1995). Dr. Meyers has been involved in sixNIH-funded clinical trials of CRA-based treatment programs at CASAA, three with NIAAA (Meyers& Miller, 2001; Miller, Meyers, & Tonigan, 1999; Smith, Meyers, & Delaney, 1998) and three withNIDA (Abbott et al., 1998; Meyers, Miller, Hill, & Tonigan, 1999; Meyers, Miller, Smith, & Tonigan,in press). He was also Project Coordinator for the Albuquerque site of Project MATCH. He alsodeveloped the Community Reinforcement and family training (CRAFT) method for engagingtreatment refusing problem drinkers in treatment via unilateral interventions through a concernedfamily member which has been found to be significantly more effective than two more commonlyused methods, Al-Anon and the Johnson Institute intervention (Miller, Meyers, & Tonigan, 1999).

3 Dr. Meyers has presented over 65 CRA and CRAFT workshops in the USA and abroad, includingAustralia, Poland, Sweden, and the D. Squires, is currently a doctoral candidate in Clinical Psychology at the University ofNew Mexico where he is also pursuing a Master's degree in Public Health. His interests within thefield of addictions research and treatment revolve around issues of motivation in the changeprocess, and he has participated as a therapist in two federally funded studies of CRA and CRAFT with treatment refusing adolescents. He is also interested in policy issues involving programevaluation and dissemination.

4 And is currently working with colleagues on developing a series ofcomputer-based brief interventions for problem drinkers that will be evaluated in a series ofupcoming controlled clinical of 3 Background for The Community Reinforcement 4 Clinical 8 CRA Functional 11 Sobriety 12 Disulfiram Use with a 12 CRA Treatment 13 behavioral Skills 15 Job 16 Social and Recreational 16 CRA's Marital 17 CRA Relapse 17 Frequently Asked 25 Recommended 25 Recommended Assessment and Treatment 26 Internet-Based 273 Overview The Community Reinforcement Approach (CRA) is a comprehensive behavioralprogram for treating substance-abuse problems.

5 It is based on the belief thatenvironmental contingencies can play a powerful role in encouraging or discouragingdrinking or drug use. Consequently, it utilizes social, recreational, familial, and vocationalreinforcers to assist consumers in the recovery process. Its goal is to make a soberlifestyle more rewarding than the use of substances. Oddly enough, however, whilevirtually every review of alcohol and drug treatment outcome research lists CRA amongapproaches with the strongest scientific evidence of efficacy, very few clinicians who treatconsumers with addictions are familiar with it.

6 The purpose of this guideline is to introduce clinicians to the use of the CommunityReinforcement Approach with consumers who present for drug and/or alcohol you complete your review of this guideline, you can expect to be better prepared towork with consumers using CRA for several reasons. First, by gaining an introductoryunderstanding of the principles underlying CRA, you will have a theoretical foundation bywhich to base your practice of this method. Second, by following the procedures outlinedin the clinical guideline, you will have a number of treatment strategies by which to developand structure an effective intervention with a variety of consumers presenting with adiversity of needs.

7 When learning any new treatment modality, it is essential to bear inmind that mastery comes only as a result of both study and practice. To that end, we havealso provided you with a resource section that we hope will serve as a useful starting pointin your effort to become more knowledgeable of, and efficient with, the practice of theCommunity Reinforcement for The Community Reinforcement Approach The Community Reinforcement Approach (CRA) is a broad-spectrum behavioralprogram for treating substance abuse problems that has been empirically supported withinpatients (Azrin, 1976; Hunt & Azrin, 1973), outpatients (Azrin, Sisson, Meyers, & Godley,1982; Mallams, Godley, Hall, & Meyers, 1982.)

8 Meyers & Miller, 2001), and homelesspopulations (Smith, Meyers, & Delaney, 1998). In addition, three recent meta-analyticreviews cited it as one of the most cost-effective alcohol treatment programs currentlyavailable (Finney & Monahan, 1996; Holder, Longbaugh, Miller, & Rubonis, 1991; Miller etal., 1995). The first study to demonstrate the effectiveness of CRA was conducted more than 25years ago (Hunt & Azrin, 1973). In this study, with 16 alcohol-dependent inpatients andmatched controls, individuals were randomly assigned to either the CRA treatment or atraditional treatment program that focused on the 12 steps of Alcoholics Anonymous (AA).

9 At the 6-month follow-up, participants in the CRA condition significantly outperformed the12-step group with the former drinking an average of 14% of the follow-up days and thelatter drinking 79% of the days. Significant differences in favor of CRA were also found forthe number of days institutionalized and employed as well. A second related study ofinpatients by Azrin (1976) again contrasted CRA with a 12 step program-this time with alarger sample. And, again, CRA proved to be superior at the 6-month follow-up, with theCRA group averaging 2% of their follow-up time drinking, as compared to 55% for thethose participating in the 12-step program.

10 As before, those treated with CRA were morelikely also to report fewer days of institutionalization and more days , the CRA condition's abstention rate at the 2-year follow-up continued to bevery high at 90%.5 Not only was the next study the first to be conducted with outpatients (n=43), but it alsowas the first to compare the effects of a disulfiram (Antabuse) compliance program withinboth CRA and 12-step programs (Azrin, Sisson, Meyers, & Godley, 1982). The disulfiramcompliance component involved training a concerned family member or friend toadminister the disulfiram to the drinker, and to provide verbal Reinforcement .